Interpretation of national policy regarding community-based use of misoprostol for postpartum hemorrhage prevention in Ethiopia: a tale of two regions.

INTRODUCTION: Postpartum hemorrhage (PPH) is responsible for a significant proportion of maternal mortality in developing countries. The uterotonic drug misoprostol (Cytotec) is a safe and effective means of preventing PPH. However, ministries of health in some countries are still grappling with policy that addresses the implementation of this targeted intervention in community settings and with communicating this policy throughout the health care system. The purpose of this study was to examine understandings of national policy for community-based use of misoprostol to prevent PPH in 2 regions of Ethiopia: Amhara and Oromiya. METHODS: Qualitative in-depth interviews were conducted with a cohort of purposefully selected health officials (N = 51) representing various administrative levels of the Ministry of Health and influential nongovernmental organizations. Broad topics included national policy for PPH prevention, safety and effectiveness of community-based use of misoprostol, and preferences for misoprostol administration. Interview transcripts were analyzed for key concepts both across and within administrative levels. RESULTS: Among all officials, understandings of national policy for community-based PPH prevention using misoprostol were unclear. Officials in Amhara tended to adopt a strict interpretation that reflected fear of misuse and a deep concern for encouraging home birth (thus deviating from the clear national goal to increase facility-based birth). Conversely, Oromiya officials framed policy in terms of the broader national goal to reduce maternal mortality, which allowed them to adopt multiple means of misoprostol distribution. DISCUSSION: The differences observed in regional practice likely stem from an ambiguously perceived national policy within a climate of decentralization that allowed for flexibility in local implementation. A policy that is clear, specific, evidence-based, and systematically communicated may facilitate common understanding of community-based misoprostol for PPH prevention and, thus, increase women's access to this lifesaving intervention.